ACTIVITY WORK PLAN 2019-2021: INTEGRATED TEAM CARE FUNDING - WENTWEST
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Activity Work Plan 2019-2021:
Integrated Team Care Funding
Western Sydney PHN
This Integrated Team Care (ITC) Activity Work Plan covers the period from 1 July 2019 to
30 June 2021 and has been endorsed by the western Sydney PHN Acting CEO.
Submitted 01 July 2019 – Version 2
1Overview
This ITC Activity Work Plan covers the period from 1 July 2019 to 30 June 2021. To assist with PHN
planning, each activity nominated in this work plan is proposed for a period of up to 24 months.
Regardless of the proposed duration for each activity, the Department of Health will require PHNs to
submit updates to the Activity Work Plan on an annual basis.
21. (a) Planned activities funded by the Indigenous
Australians’ Health Program Schedule for Integrated
Team Care Funding
Proposed Activity 1 - Care coordination and supplementary services
ACTIVITY TITLE ITC1 – Care coordination and supplementary services
Program Key
Indigenous Health
Priority Area
Needs Improve Aboriginal and Torres Strait Islander people’s access to high quality,
Assessment culturally appropriate health care, including care coordination services.
Priority
Contribute to improving health outcomes for Aboriginal and Torres Strait
Aim of Activity Islander people with chronic health conditions through better access to care
coordination, multidisciplinary care, and support for self-management.
A description of the Integrated Team Care (ITC) model for this activity, including
how the activity and care coordination services will be delivered is as follows;-
WSPHN has utilised the feedback from a consultation process to design a multi-
faceted commissioning process to deliver ITC services.
The existing provider has decided not to continue to undertake the ITC program
therefore we will transition this service to other providers in the region. A
proportion of the funding will be provided to service providers to expand their
services and outcomes. For the remaining funds a competitive process which
may include competitive dialogue or selected/ invited tendering, will be
conducted involving potential new providers from the region to create either a
prime contractor model or a consortium of service providers who will co-design
the services and work in collaboration to deliver services in the region.
This approach will help us build new capabilities and service delivery capacity in
the region for the communities to meet program goals.
Description of
Activity As a Commissioner of Services Western Sydney PHN (WSPHN) will:
- Conduct market engagement by direct invitation to potential providers
(market sounding).
- Support commissioned service providers to manage the ITC program and
promote this to clients and the communities they are engaging with.
- Performance manage and evaluate services.
The WSPHN will also:
- Employ an Indigenous Health Project Officer (IHPO) to work as a team
leader to provide strategic direction for the team and develop and
implement a coordinated team-based approach for the ITC program.
- In addition to the above the IHPO will be responsible for coordinating
supplementary services and ensure appropriate utilisation of these funds.
- Increase awareness of and maximise links between services for Aboriginal
and Torres Strait Islander people, including those provided by
commonwealth, state and local governments and other organisations.
- Collaborate with local indigenous and mainstream health services in a
partnership approach for the delivery of primary care services.
3- Ensure support is also provided to all mainstream primary care providers to
facilitate clients having access to ITC services.
- Manage the cultural awareness program and ensure support is provided to
all mainstream primary care providers to facilitate clients having access to
ITC services.
Through this activity Commission Providers will:
- Be contracted to deliver the care coordination component of the ITC
program. Access to the service will be via referral from a local service
provider or mainstream GP.
- Employ Care Coordinators and Outreach workers
- Support Care Coordinators and Outreach workers in their roles to ensure
optimum outcomes for the community.
- Identify Aboriginal and/or Torres Strait Islander clients who are eligible for
the ITC program.
Through this activity the Indigenous Health Project Officer (IHPO) will:
- Lead the team, coordinate and manage the ITC program. The role will
develop a robust team based approach to the delivery of the program and
ensure geographical coverage.
- Continue to promote the ITC program with primary care and pharmacy
providers and provide information about the program across the region.
- Provide operational and strategic support to build and develop effective
health care models and service delivery activities to improve the health and
wellbeing of Aboriginal and Torres Strait Islander people and communities.
- Also work closely with Practice Support teams to promote MBS Health
Checks and Indigenous PIP and will deliver cultural competency training
across the region for mainstream practices including coaching and
mentoring in primary care settings to improve cultural safety.
- Provide ITC program monitoring and reporting, support and lead
community development activities
- Provide guidance in organisational planning, policy and needs analysis
initiatives and develop and facilitate service system education and capacity
building initiatives.
- Be responsible for coordinating supplementary services and ensure
appropriate utilisation of these funds
Through this activity Care Coordinators will:
- Be allocated to clients to assist in their care and make direct contact to
arrange an initial appointment
- Complete a holistic assessment and liaise with other health professionals
involved in care to determine their goals and needs
- Together with the client develop a care plan which includes building the
patients understanding of their chronic disease, determining their needs,
setting goals and education around management
- Develop and maintain a close relationship with their client’s GP to help
bridge the gap
- Assist clients to access a range of services such as appointments with
specialists and allied health professionals, arrangements for home help and
making connections with support groups
- Improve their client’s capacity to engage with the broader health system
- Identify when a client’s condition may require further assistance from a
health professional
4- Assist clients to adhere to treatment regimens, develop chronic condition
self-management skills and connect with appropriate clinical care
- Set up regular appointments with the client to monitor the patients
progress against their goals.
Through this activity Outreach Workers will:
- Support patients to access services by aiding with transport
- Take part in Community liaison activities
- Undertake administration and support
- Provide practical assistance
- Provide feedback regarding access problems
Workforce Type FTE ACCHO/ PHN
MPS
Indigenous Health Project Officers 1 1
Care Coordinators 2 2
Outreach Workers 3 3
Workforce development provided for staff is intended to be strengths-based
and forward-looking. It seeks to build on existing workforce strengths,
capabilities and resources while also identifying the resources that might be
needed in future.
Workforce development opportunities for staff under this activity include:
- All staff having a workforce development plan in place
- Provision of access to sector capacity building activities
- Provision of access to networking opportunities
- Provision of resources that enhance capacity in working with families and
significant others, including children
- Provision of professional development opportunities, including initiatives
that enhance capacity in:
- Cultural responsivity and cultural awareness
- Responding to complex needs, (i.e.: Trauma Informed care)
- Supporting and engaging clients with chronic conditions
- Access to online training and education initiatives.
- Access to in-service presentation focusing on the importance of the Council
of Australian Government (COAG) targets, identification, barriers to
identification, cultural safety, etc
- Facilitate Accredited (RACGP) cultural awareness training for the “Practice
Incentives Program Indigenous Health Incentive” for general practice and
their staff.
Target Aboriginal and Torres Strait Islander people with a diagnosed chronic condition
population
cohort
Indigenous Yes
specific
Coverage Whole PHN Region
Stakeholder engagement and consultation activities undertaken to support this
activity are:
Consultation - Talking with community members, Elders and service providers when
undertaking the Needs Assessment
- Engaging with Aboriginal and Torres Strait Islander health organisations.
5- Local health care stakeholders, including LHD’s and SCHN and other local
stakeholders relevant to addressing health matters
- Clinical and Consumer Councils providing advice and input in plans
- Local Indigenous health services and mainstream primary health services in
a partnership approach for the delivery of primary care services
Further consultation will be conducted throughout the plan period to ensure
the services being delivered are in line with stakeholder and community needs
and priorities for the ITC program.
WSPHN works in collaboration with the following stakeholders to inform the
needs of the community and to determine locally appropriate and integrated
service solutions:
- Marrin Weejali
- Aboriginal and Torres Strait Islander Communities (including men, women,
Collaboration and children)
- WSLHD, SCHN
- GP practices
- Other local Health care providers
- Greater Western Aboriginal Health Service
- Peak bodies
Activity Activity is valid for full duration of AWP
milestone details
1. Please identify your intended procurement approach for commissioning
services under this activity:
☐ Not yet known
☐ Continuing service provider / contract extension
☐ Direct engagement. If selecting this option, provide justification for direct
engagement, and if applicable, the length of time the commissioned
provider has provided this service, and their performance to date.
☐ Open tender
Commissioning
method and ☒ Expression of Interest (EOI)
approach to ☒ Other approach (please provide details) Direct approach
market 2a. Is this activity being co-designed?
Yes
2b. Is this activity this result of a previous co-design process?
Yes
3a. Do you plan to implement this activity using co-commissioning or joint-
commissioning arrangements?
No
3b. Has this activity previously been co-commissioned or joint-commissioned?
No
Decommissioning
Funding from
other sources
6Proposed Activity 2
ACTIVITY TITLE ITC2 – Culturally competent mainstream services
Program Key
Indigenous Health
Priority Area
Needs Improve Aboriginal and Torres Strait Islander people’s access to high quality,
Assessment culturally appropriate health care, including care coordination services.
Priority
Improve access to culturally appropriate mainstream primary care services
Aim of Activity (including but not limited to general practice, allied health, and specialists) for
Aboriginal and Torres Strait Islander people
Western Sydney PHN will directly employ 1.0 FTE Cultural Aboriginal Liaison
Coordinator to undertake this activity.
The ITC model for this activity has taken into account the unique operating
cultures and distinctive needs of Aboriginal and Torres Strait Islander people.
The description of the ITC model for this activity includes:
- Workforce analysis –
o Undertake a workforce survey to identify cultural development
needs and general practice quality improvement opportunities.
- Gap Analysis
o Identify new skills the workforce will need to provide culturally
competent mainstream services
- Strategy development
o to address future gaps and include programs, policies, and
practices that assist an organisation to be culturally competent.
o to build capacity by shaping and developing staff capabilities
and prepare employees for new roles or responsibilities
- Implement workforce plan -
o Communicate improvement plans to mainstream primary care
Description of
providers
Activity
o Allocate necessary resources to carry out identified strategies
o Clarify roles and responsibilities in implementing the strategies.
o Define performance measures, milestones & deliverables
- Monitoring and Evaluation
o Access what is working and what is not working
o Make any adjustments to the model
o Address new organisational issues that affect the plan
Additional work to be undertaken as part of this activity include: -
- Facilitating access to resources that support cultural workforce
planning and development
- Showcasing approaches that support integrated care, including
integrated pathways, linkages and models of care
- Facilitating training to improve the capacity of mainstream primary care
providers to confidently deliver safe, accessible and culturally
responsive services
- Facilitating cultural competency training for commissioned providers
- Increasing the uptake of specific Aboriginal and Torres Strait Islander
MBS items including 715 – Health Assessment for Aboriginal and Torres
Strait Islander people, care planning and follow-up items.
7- Developing linkages, pathways and other approaches that support
cross-sector networking, information and knowledge exchange
- Assisting practices to encourage Aboriginal and Torres Strait Islander
patients to self-identify
- Developing culturally appropriate terminology cheat sheets
- Helping practices create a more welcoming environment e.g.,
Indigenous artwork and posters.
Workforce Type FTE AMS MPC PHN
Indigenous Health Project Officers
Outreach Workers
Consultants
Other: specify PHN 1 1
Workforce development provided for staff is intended to be strengths-based
and forward-looking. It seeks to build on existing workforce strengths,
capabilities and resources while also identifying resources that might be
needed in future.
Workforce development opportunities for staff under this activity include:
- Staff having a workforce development plan in place
- Provision of access to sector capacity building activities.
- Provision of access to networking opportunities.
- Provision of resources that enhance capacity in working with families
and significant others, including children.
- Provision of professional development opportunities, including
initiatives that enhance capacity in:
- Cultural responsivity and cultural awareness
- Responding to complex needs, (i.e.: Trauma Informed care)
- Supporting and engaging clients with chronic conditions
- Access to online training and education initiatives.
- Access to in-service presentation focusing on the importance of the
Council of Australian Government (COAG) targets, identification,
barriers to identification, cultural safety, etc
- Facilitate Accredited (RACGP) cultural awareness training for the
“Practice Incentives Program Indigenous Health Incentive” for general
practice and their staff.
Target Aboriginal and Torres Strait Islander people with a diagnosed chronic condition
population
cohort
Indigenous Yes
specific
Coverage Whole PHN region
- Talking with community members, Elders and service providers
- Aboriginal and Torres Strait Islander health and social care providers
- GPs, Allied Health, Pharmacist and Specialist providers
- Local health care stakeholders, including Western Sydney Local Health
Consultation District and other local stakeholders relevant to addressing health
matters.
- Further consultation will be conducted throughout the plan period to
ensure the services being delivered are in line with stakeholder and
community needs and priorities for the ITC program.
8Below is a list and description of the role of each stakeholder that will be
involved in designing and/or implementing the activity;-
- Local Primary Healthcare Providers: Participation in working groups and
workforce development
- National and State Peak Bodies: Peak bodies are often engaged in the
development of pathways providing up to management guidelines, and
national and state health policy
- Local Aboriginal NGO’s and community health groups – Consultation and
Collaboration participation in working groups. Provide advice on emerging issues, joint
planning of initiatives including education and health promotion activities
- GP and local healthcare professionals training and education is jointly
planned with RACGP and WSLHD to support local education to GPs and
practice nurses, including cultural competency training.
- WSLHD and SCHN Consultation and planning
- Aboriginal Organisations (Marrin Weejali, Babayan) consultation and
collaboration to deliver this activity
- WSPHN internal GP focus team consultation and planning
Activity Activity is valid for full duration of AWP
milestone details
1. Please identify your intended procurement approach for commissioning
services under this activity:
☐ Not yet known
☐ Continuing service provider / contract extension
☐ Direct engagement. If selecting this option, provide justification for direct
engagement, and if applicable, the length of time the commissioned
provider has provided this service, and their performance to date.
☐ Open tender
Commissioning
method and ☐ Expression of Interest (EOI)
approach to ☒ Other approach (please provide details) PHN will employ 1 FTE.
market 2a. Is this activity being co-designed?
No
2b. Is this activity this result of a previous co-design process?
No
3a. Do you plan to implement this activity using co-commissioning or joint-
commissioning arrangements?
No
3b. Has this activity previously been co-commissioned or joint-commissioned?
No
Potential implications decommissioning this activity are unknown at this stage.
Decommissioning
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